Health Service Delivery Integration for Rural Older Adults with Atrial Fibrillation: Patient and Provider Perspectives K. Rush1, ND. Oelke1, C. Laberge2, F. Louw1,3, C. Reid1, M. Kjorven2, M. Shay1, & L. Gardner1,2
Background • Older adults with atrial fibrillation (AF) are one of Canada’s fastest growing cohorts. Increase per decade: 6% in 65 to 74 year olds to 16% in those 85 years and over • Most commonly managed arrhythmia in ED, accounts for 1/3 of older adult hospitalizations for cardiac rhythm disturbances, and increases stroke risk 5-fold
Health Service Delivery Integration
Purpose To describe current service delivery from the perspective of patients and providers through the lens of integration principles.
Access: Challenged with accessing both routine and
Access: Perceived barriers for patients to specialty care (eg.
emergency care; relied heavily on ambulance services; satisfaction with access influenced by symptom severity, presence of co-morbidities, range of options to access
travel) and limited access to resources/services (eg. medications, laboratory services)
Methods
Long-term management: Expected to self-manage often
• Qualitative, embedded quantitative mixed methods design • Participants were rural adults with AF with a CHADS2 score of >1 recruited through local primary care physicians • Journey: 10 older adults were followed over 6 months in order to map their journey with AF through a combination of interviews, telephone conversations, logs, photos and chart review. • Focus groups: 3 older adults, 3 provider
through trial and error with limited provider support
Patient-provider relationship: Perceived as positive and
Variable
n
Patient coordination due to provider stability and closer relationships
Provider Demographics Variable
n
Care outside of the community: Experienced coordination due to gaps in discharge planning; had faith in electronic communication and information flow
Age
74.71
17
Age
39
8
Sex
Male
7
Sex
Male
3
Female AF Diagnosis
10
< 2 years
4
2 – 5 years > 5 years
Female Position
Patient Centered Care Care responsive to patients' needs and desires and not provider’s
5
Physician
3
3
Nurse
3
10
Pharmacist
1
Patient Effective team functioning: Perceived providers as collaborative and inclusive of professionals and nonprofessionals. At times made assumptions about team that led to communication breakdowns
Long-term management: Experienced challenges with providing ongoing educational support due to lack of time and resources
Patient-provider relationship: Providers sometimes withheld information for perceived patient good but denied patients a voice; communication breakdowns delayed access
gave voice; influenced by length of relationship, age, feeling like a team member
Care within the community: Perceived easier
Patient Demographics
Provider
Patient
Coordination of Care Services Care across the continuum (primary through tertiary)
Provider Care within the community: Viewed proximity as expediting care coordination
Care outside of the community: coordination due to poor information flow; improvised to prevent patients from falling through the cracks; viewed having the players but not the communication.
Provider
Interprofessional Collaboration
Ineffective team functioning: Sporadic, unplanned
Collaboration to provide standardized care across the continuum
Role confusion: Feeling pressured to manage
and reactive collaboration
symptomatic patients with little cardiology support; questioned need for expanded pharmacy and PN role
Few standards of care: Except for Warfarin-INR Administrator
1
References Fitzmaurice, D.A. et al (2007). Screening versus routine practice for detection of AF in people aged 65 or over: cluster randomized control trial. British Medical Journal, 335, 383-6. Fuster, V. et al. (2006). ACC/AHA?ESC 2006 guidelines for the management of patient with atrial fibrillation. Journal of the American College of Cardiology, 48, 149-246. Gillis, A.M. et al (2008). Treating the right patient at the right time: An innovative approach to the management of atrial fibrillation. Canadian Journal of Cardiology, 24(3), 195-198.
1
2
algorithm that delegated to office assistants
“Just call 911 and they’re right at the door.” (Patient)
“We don't really have a good way of communicating.” (Rural physician)
Implications • Disconnects led patients to experience false confidence in health care • Forced self-management for which patients were often unprepared especially in crisis situations • Integration could be improved through standardization of care, increased telehealth options and improved education and self-management support through initial stages of the disease
3
Chisel Peak Medical Clinic Invermere, BC
Acknowledgments: Funding provided by CIHR. Special thanks to the older adult and the healthcare provider participants for making this study possible.